Care Manager | ECM - Orange County
Amity Foundation, an internationally acclaimed Teaching, and Therapeutic Community is seeking compassionate and enthusiastic individuals with a desire to teach, learn and join our community as a ECM Advocate. This groundbreaking opportunity will allow you to work with our prison and re-entry programs helping the community and will also enhance your training and experience in the field.
About Amity:
Amity Foundation is a safe place where people can change in an environment that fosters trust; where new values can be formed; responsibility developed, and lasting relationships built. Amity is dedicated to the inclusion and habilitation of people marginalized by addiction, homelessness, trauma, criminality, incarceration, poverty, racism, sexism, and violence. Amity is committed to research, development implementation, and dissemination of information regarding community building.
Remembrance, Resolution, Reconciliation, Restoration, Renewal
About the Position:
The Enhanced Care Management (ECM) Advocate is responsible for the and coordination, improving health outcomes, enhancing satisfaction, and reducing unnecessary healthcare utilization. ECM is a comprehensive, patient-centered approach to healthcare that aims to improve outcomes for high-need populations. This involves the coordination of medical, behavioral, and social services to address the full range of patient needs, focusing on those with complex and chronic conditions. ECM programs are designed to optimize care delivery, reduce unnecessary hospitalizations, and improve the overall quality of life for . The intention of our services is to help people who have not been able to get the needed help in terms of Housing, Mental Health, Substance Abuse treatment, and linkages to community resources to help minimize recidivism. The role of the ECM Advocate is to help create a supportive network of services and resources for the client to prevent reincarceration and support long term permanent housing goals.
This position specifically serves students across Orange County, including both in-custody services within county jail settings andpost-release services in the community. The ECM Advocate must be comfortable working in secure correctional environments and in the field, ensuring continuity of care from incarceration through successful community reintegration. This role requires strict adherence to county jail access protocols, safety procedures, and visiting regulations, while also maintaining flexibility to meet students in community-based settings throughout the county.
What You Will Do:
• Conduct outreach to identify and engage eligible in ECM services, using multiple strategies and modalities for engagement.
• Interview and conduct assessments of students’ needs, including medical, behavioral, and social factors.
• Develop, implement, and monitor personalized care plans in collaboration with students, their families, healthcare providers, and community resources.
• Monitor and evaluate the effectiveness of care plans and making adjustments as needed to student goals.
• Serve as the primary point of contact for the student, relevant family members, and other supports.
• Operate as part of the student’s multi-disciplinary care team.
• Coordinate care across multiple providers and services, ensuring seamless integration of medical and social care.
• Act as a student advocate, ensuring the student’s needs and preferences are central to care decisions.
• Facilitate regular team meetings to review patient cases, address challenges, and share successes.
• Travel locally to deliver services to students in the community where they live, work, or frequent.
• Document services in the agency’s Electronic Health Record within 72 hours of each service and in compliance with agency policy, as well as contractual, state, and federal regulations.
• Coordinate and link the client to needed mental health, substance abuse, and housing resources.
• Maintained concise and comprehensive case records on all participants seeking services.
• Provide accurate daily and monthly documentation and case notes as per funding source guidelines.
• Attend workshops, meetings, and trainings as requested by supervisor.
• Provide in-person pre-release case management services within Orange County jail facilities, including conducting assessments, initiating care plans, and engaging students before release.
• Complete and maintain clearance for county jail access, including passing all required background checks and complying with facility-specific rules and regulations at all times.
• Adhere to all county jail visiting policies, procedures, and security protocols, demonstrating professionalism and compliance in a custodial setting.
• Deliver comprehensive pre-release planning, including development of individualized care plans, coordination of benefits, and linkage to housing, medical, and behavioral health services.
• Conduct post-release follow-up services in the community, ensuring continuity of care and successful transition from custody to community-based support systems.
• Schedule and coordinate medical and behavioral health appointments for students upon release, ensuring access to immediate and ongoing care.
• Provide transportation support upon release, including picking up students from local custody facilities and transporting them to approved destinations such as housing placements, shelters, or family residences.
• Facilitate enrollment into Enhanced Care Management (ECM) services, ensuring all eligibility, documentation, and onboarding requirements are completed accurately and in a timely manner.
• Balance responsibilities across both custodial (jail-based) and community-based service delivery, demonstrating adaptability and strong time management skills.
• Performs other related duties as assigned.
• Interview and conduct assessments of students’ needs, including medical, behavioral, and social factors.
• Develop, implement, and monitor personalized care plans in collaboration with students, their families, healthcare providers, and community resources.
• Monitor and evaluate the effectiveness of care plans and making adjustments as needed to student goals.
• Serve as the primary point of contact for the student, relevant family members, and other supports.
• Operate as part of the student’s multi-disciplinary care team.
• Coordinate care across multiple providers and services, ensuring seamless integration of medical and social care.
• Act as a student advocate, ensuring the student’s needs and preferences are central to care decisions.
• Facilitate regular team meetings to review patient cases, address challenges, and share successes.
• Travel locally to deliver services to students in the community where they live, work, or frequent.
• Document services in the agency’s Electronic Health Record within 72 hours of each service and in compliance with agency policy, as well as contractual, state, and federal regulations.
• Coordinate and link the client to needed mental health, substance abuse, and housing resources.
• Maintained concise and comprehensive case records on all participants seeking services.
• Provide accurate daily and monthly documentation and case notes as per funding source guidelines.
• Attend workshops, meetings, and trainings as requested by supervisor.
• Provide in-person pre-release case management services within Orange County jail facilities, including conducting assessments, initiating care plans, and engaging students before release.
• Complete and maintain clearance for county jail access, including passing all required background checks and complying with facility-specific rules and regulations at all times.
• Adhere to all county jail visiting policies, procedures, and security protocols, demonstrating professionalism and compliance in a custodial setting.
• Deliver comprehensive pre-release planning, including development of individualized care plans, coordination of benefits, and linkage to housing, medical, and behavioral health services.
• Conduct post-release follow-up services in the community, ensuring continuity of care and successful transition from custody to community-based support systems.
• Schedule and coordinate medical and behavioral health appointments for students upon release, ensuring access to immediate and ongoing care.
• Provide transportation support upon release, including picking up students from local custody facilities and transporting them to approved destinations such as housing placements, shelters, or family residences.
• Facilitate enrollment into Enhanced Care Management (ECM) services, ensuring all eligibility, documentation, and onboarding requirements are completed accurately and in a timely manner.
• Balance responsibilities across both custodial (jail-based) and community-based service delivery, demonstrating adaptability and strong time management skills.
• Performs other related duties as assigned.
What You Will Bring:
Education and Experience:
Required:
• Bachelor’s degree in social work, psychology, public health, or related field; or Associate’s degree
• A minimum of two years’ experience in a client-related field, providing case management and community outreach.
OR
• The equivalent of a high school diploma and three cumulative (3) years of experience of administrative responsibility in providing outreach, substance abuse counseling, reentry services, and case management within a culturally diverse population.
• Must be able to pass a comprehensive background check and obtain clearance to enter and work within Orange County jail facilities.
• Experience working with justice-involved or formerly incarcerated populations strongly preferred.
• Comfortable working in both secure custodial environments and community-based field settings.
• Strong communication and interpersonal skills, capable of building relationships with students, families, team members, and community partners.
• Understand various ethnic and socioeconomic backgrounds within a multicultural environment.
• Knowledge of how to administer assessments, substance abuse counseling, reentry services, and case management within a culturally diverse population, preferably with both men and women.
• This position requires local travel and the ability to navigate public transportation with students.
• Required to use company vehicle as well as personal vehicle to visit county jails and transport clients to and from appointments and other locations as needed.
• Required to have car insurance, a vehicle, and a valid driver’s license
Preferred: Bilingual, fluent Spanish/English oral and written skills are highly desirable.
Certifications or Licenses:
• Required: NONE.
• Preferred: Community Health Worker certification through California’s HCAI Department.
• Driver’s License
Skills/Abilities:
• Excellent interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in the community and within the organization.
• Knowledge of contract parameters, objectives, milestones, and other deliverables.
• Knowledge of contracting process and associated local, state, federal, and other regulations.
• Ability to integrate budgetary and service utilization data, forecast expenditures, and respond to ensure both effective provider utilization and budget compliance.
• Ability to multi-task, identify problems, provide recommendations to management teams, and implement any applicable systems.
• Ability to work constructively with diverse people and with parties that may have divergent perspectives and interests.
• Ability to clearly express concepts and direction, both orally and in writing, and to prepare complex reports, policies, and procedures.
• Understand and appropriately apply Amity policies and procedures and adhere to agency-wide practices and regulations.
• Strong oral and written communication skills.
• Proficient with software such as Microsoft Office Suite (Word, Excel. Email, Internet, etc.).
ADA Information:
Physical Requirements:
• Faculty must frequently lift and/or move up to 50 pounds.
• Frequently required to sit and/or stand for extended periods of time.
• Frequently required to type for extended periods of time.
• Occasionally required to reach, walk, climb, pull, push, grasp, stretch, stoop.
• Frequently required to talk, hear, see, and use repetitive motions.
• Frequently able to communicate in verbal and written form.
• Frequently able to use all types of vision, such as close vision, distance vision, color vision, peripheral vision, and depth perception, to complete daily tasks.
• Required to wear comfortable and office appropriate clothes.
Mental Demands:
• Ability to change direction as priorities shift.
• Ability to thrive in an environment that requires one to adapt to changing circumstances.
• Ability to professionally work under pressure with difficult or temperamental & faculty.
• Ability to handle mental and emotional stress related to the position.
Work Conditions:
• Generally, in an indoor office setting.
Environmental Conditions:
• The noise level in the work environment is moderate but can be loud.
• The temperature in the work environment is usually moderate to cool but can be cold or hot.
Travel:
• May travel locally by vehicle.